Certificate of Death - Physician's Form: Undertaker's Certificate and Record of Death of Anna Sarire Weber

CERTIFICATE OF DEATH-PHYSICIAN'S FORM
UNDERTAKER'S REGISTERED No.________
CERTIFICATE AND RECORD OF DEATH DEPARTMENT OF HEALTH
OF CITY OF CHICAGO
1. FULL NAME Anna Sarire Weber__________________________________10. HOW LONG RESIDENT IN CITY Life_______
2. (a) SEX F (b) COLOR W (c) SINGLE MARRIED WIDOWED DIVORCED Single 11. HOW LONG IN STATE Same________
3. (a) BIRTHPLACE Chicago (b)DATE OF BIRTH January 31, 1912_______12. HOW LONG IN U.S. IF FOREIGN BORN
4. AGE 1__ YEARS 11__ MONTHS 12__ DAYS ____ HOURS 13. (a) NAME OF FATHER Michael Weber________
5. DIED ON THE 12_ DAY OF January_ 1914 AT ABOUT 8 a.m. (b) BIRTHPLACE OF FATHER Chicago
6. LAST OCCUPATION (a) __________ ______ (b) ___________________ 14. (a) MAIDEN NAME OF MOTHER Carrie Becker
FROM THE YEAR (c) ______________ TO THE YEAR ______________ (b) BIRTHPLACE OF MOTHER Chicago______
7. FORMER OCCUPATION (a) _______________ (b) __________________ The foregoing stated personal particulars are true to the
FROM THE YEAR (c) ______________ TO THE YEAR______________ best of my knowledge and belief:
8. (a) PLACE OF DEATH Tessvill [sic] HOW LONG AT PLACE OF DEATH one day 15. INFORMANT Michael Weber
9. (a) USUAL RESIDENCE Niles Center ________(b)WARD ____________ ADDRESS Niles Center__
PLACE OF BURIAL St. Peters Niles Center 17. UNDERTAKER N P Weimeschkirch_____ License No.
16. DATE OF BURIAL January - 14 - 1914__ ADDRESS 7066 N. Clark St ___ _________
HOUR 2 PM. TELEPHONE Evanston 1065
PHYSICIAN'S CERTIFICATE OF CAUSE OF DEATH
I HEREBY CERTIFY THAT I ATTENDED DECEASED FROM January 11 1914 TO January 12 1914 THAT I LAST SAW her ALIVE ON THE 11 DAY OF January 1914 THAT she DIED ON THE DAY AND AT ABOUT THE HOUR STATED ABOVE, AND THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF THE CAUSE OF _____ DEATH WAS AS HEREUNDER WRITTEN.
(IF UNDER ONE YEAR OLD, STATE HOW FED)
(a) CAUSE OF DEATH Burned by falling in hot ashes DURATION* IN YEARS MONTHS, DAYS OR HOURS ____________(Lower half of body and left arm)_________________
(b) CONTRIBUTORY (SECONDARY) Shock - inhalation of hot gas fumes *Of each Cause according to the Clinical History.
Witness my hand THIS 14___ (SIGNATURE) A. Louise Klehm__ M.D.
DAY OF January _________1914 ADDRESS Niles Center, Ill. TELEPHONE 12 R.

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CERTIFICATE OF DEATH-PHYSICIAN'S FORM
UNDERTAKER'S REGISTERED No.________
CERTIFICATE AND RECORD OF DEATH DEPARTMENT OF HEALTH
OF CITY OF CHICAGO
1. FULL NAME Anna Sarire Weber__________________________________10. HOW LONG RESIDENT IN CITY Life_______
2. (a) SEX F (b) COLOR W (c) SINGLE MARRIED WIDOWED DIVORCED Single 11. HOW LONG IN STATE Same________
3. (a) BIRTHPLACE Chicago (b)DATE OF BIRTH January 31, 1912_______12. HOW LONG IN U.S. IF FOREIGN BORN
4. AGE 1__ YEARS 11__ MONTHS 12__ DAYS ____ HOURS 13. (a) NAME OF FATHER Michael Weber________
5. DIED ON THE 12_ DAY OF January_ 1914 AT ABOUT 8 a.m. (b) BIRTHPLACE OF FATHER Chicago
6. LAST OCCUPATION (a) __________ ______ (b) ___________________ 14. (a) MAIDEN NAME OF MOTHER Carrie Becker
FROM THE YEAR (c) ______________ TO THE YEAR ______________ (b) BIRTHPLACE OF MOTHER Chicago______
7. FORMER OCCUPATION (a) _______________ (b) __________________ The foregoing stated personal particulars are true to the
FROM THE YEAR (c) ______________ TO THE YEAR______________ best of my knowledge and belief:
8. (a) PLACE OF DEATH Tessvill [sic] HOW LONG AT PLACE OF DEATH one day 15. INFORMANT Michael Weber
9. (a) USUAL RESIDENCE Niles Center ________(b)WARD ____________ ADDRESS Niles Center__
PLACE OF BURIAL St. Peters Niles Center 17. UNDERTAKER N P Weimeschkirch_____ License No.
16. DATE OF BURIAL January - 14 - 1914__ ADDRESS 7066 N. Clark St ___ _________
HOUR 2 PM. TELEPHONE Evanston 1065
PHYSICIAN'S CERTIFICATE OF CAUSE OF DEATH
I HEREBY CERTIFY THAT I ATTENDED DECEASED FROM January 11 1914 TO January 12 1914 THAT I LAST SAW her ALIVE ON THE 11 DAY OF January 1914 THAT she DIED ON THE DAY AND AT ABOUT THE HOUR STATED ABOVE, AND THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF THE CAUSE OF _____ DEATH WAS AS HEREUNDER WRITTEN.
(IF UNDER ONE YEAR OLD, STATE HOW FED)
(a) CAUSE OF DEATH Burned by falling in hot ashes DURATION* IN YEARS MONTHS, DAYS OR HOURS ____________(Lower half of body and left arm)_________________
(b) CONTRIBUTORY (SECONDARY) Shock - inhalation of hot gas fumes *Of each Cause according to the Clinical History.
Witness my hand THIS 14___ (SIGNATURE) A. Louise Klehm__ M.D.
DAY OF January _________1914 ADDRESS Niles Center, Ill. TELEPHONE 12 R.